Antenatal depression and its predictors among HIV positive women in Sub-Saharan Africa; a systematic review and meta-analysis

Background Antenatal depression in Human Immunodeficiency Virus (HIV) positive pregnant women can have significant adverse effects on both the mother and newborns, yet it is often overlooked in pregnancy care in Sub-Saharan Africa (SSA). Despite this, there is limited data on the combined prevalence of antenatal depression and its predictors among HIV-positive women in the region. Objective To assess the pooled prevalence of antenatal depression and its associated factors among HIV-positive women in SSA. Methods All primary cross-sectional studies published before 1st January/2024, were included. We conducted searches in relevant databases; PubMed, HINARI, Web of Science, PsycINFO, Psychiatry Online, ScienceDirect, and Google Scholar. The Joanna Briggs Institute checklist was used to critically appraise the selected studies. To assess heterogeneity among the studies, we utilized the I2 test. Publication bias was evaluated using a funnel plot and Egger’s test. The forest plot was used to present the combined proportion of antenatal depression and odds ratio, along with a 95% confidence interval. Results The pooled prevalence of antenatal depression among HIV-positive women in Sub-Saharan Africa was found to be 30.6% (95% CI, 19.8%-41.3%). Factors significantly associated with antenatal depression among HIV-positive women in SSA included being unmarried (AOR: 3.09, 95% CI: 1.57 – 6.07), having a previous history of depression (AOR: 2.97, 95% CI: 1.79 – 4.91), experiencing intimate partner violence (IPV) (AOR: 2.11, 95% CI: 1.44 – 3.09), and experiencing stigma (AOR: 1.36, 95% CI: 1.05 – 1.76). Conclusion High prevalence of antenatal depression among HIV-positive women in SSA underscores the need for prioritizing identification and management. Interventions addressing factors like IPV and stigma, along with training for healthcare providers in recognizing symptoms and providing support, are recommended. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42024508236.


Introduction
Antenatal depression is a common mental health disorder that affects pregnant women worldwide (1), with lower and middleincome countries bearing the highest burden (2).In Sub-Saharan Africa (SSA), where the prevalence of HIV is high (3), antenatal depression is a significant public health concern among HIV positive women (4)(5)(6).Serious forms of depression characterized by the idea of suicide or self-harming are common during pregnancy (7).
By 2030, depression and HIV/AIDS are expected to be the main global disease burdens (21).To improve mental health, national and international strategies have been implemented for vulnerable groups like postpartum women, and those living with HIV/AIDS (22,23).However, in SSA, antenatal depression with HIV-positive women is prevalent, as the primary studies conducted in different places in the region have indicated (2,13,(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34).HIV has been documented to have effects on the fetus, including low birth weight, preterm births, small for gestational age, delayed cognitive and language development, behavioral problems, poor academic performance, and emotional issues (35)(36)(37).
These primary studies were conducted in a fragmented manner across different SSA countries, and the pooled prevalence of antenatal depression among HIV-positive pregnant women has not been determined in SSA.Therefore, in this systematic review and meta-analysis, we aimed to synthesize the available evidence on the pooled prevalence of antenatal depression and its predictors among HIV positive women in SSA.The findings will provide valuable insights into the burden of antenatal depression in this population, inform the development of effective interventions, and contribute to the achievement of Sustainable Development Goal (SDG) 3, which aims to ensure healthy lives and promote well-being for all at all ages by 2030.

Study setting and period
We included studies conducted among countries listed in the Sub-Saharan Africa region.The search period was from October 1, 2023 to January 1, 2024.
proportion or prevalence of antenatal depression among HIV positive women were the target of this review.All primary crosssectional studies published before January 1, 2024 were included.The search was done using keywords such as antenatal depression, or depression in antenatal period, depression during pregnancy and associated factors, or determinants, or predictors, and country found in Sub-Saharan Africa.Combinations of Boolean operators (AND, OR), free keywords, and MeSH terms were used in the search process (Additional File 1).

Eligibility criteria
The inclusion criteria encompassed: (1) studies conducted in Sub-Saharan Africa country, (2) all cross-sectional studies, (3) studies reporting the prevalence of antenatal depression and/or associated or determinant factors or predictors, and (4) studies published as fulllength articles in English.Whereas, conference papers or abstracts, articles lacking full texts, anonymous reports, editorial reports, and qualitative studies were not included in this study.

Data extraction
The data from all the studies included in the analysis were collected and organized in a customized Microsoft Excel spreadsheet.This extraction process was carried out by three authors (GA, DG, AA, and MA) using a standardized extraction form.In case of any discrepancies between the data extractors, discussions were held and resolved by the three authors (AA, TT, and DA).We extracted important information from each study, which included the author's name, publication year, antenatal depression event, prevalence, country, study design, and associated factors such as odds ratios.

Quality assessment/critical appraisal
The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for cross-sectional studies was used to assess the quality of the study (42).Two authors (GA and AA) independently assessed the quality of each article using a critical appraisal checklist adapted from JBI.During the critical appraisal process, if any discrepancies arose, the reviewers held discussions led by the fourth author (TT) to address and resolve the issues.Finally, a total of 13 studies that fulfill the inclusion criteria were considered in this meta-analysis (Additional File 2).

Statistical analysis
Data entry was performed using the Microsoft Excel Database, and the entered data was subsequently imported into R software version 4.1.3for further analysis utilizing the Meta-package.The heterogeneity between studies was evaluated using the I 2 index (43), where values of 25%, 50%, and 75% indicated low, medium, and high heterogeneity, respectively (44).Publication bias was evaluated by visually inspecting the symmetry of the funnel plot and conducting the Egger test.A p-value of less than 0.05 on the Egger test indicated the presence of publication bias among the included studies.In order to identify potential sources of heterogeneity, a univariate Meta-regression analysis was conducted, taking into account the sample size and year of publication.Additionally, a leave-one-out sensitivity analysis was performed, systematically removing one study at a time to assess the impact of each individual study on the overall estimate (45).Furthermore, a trim-and-fill analysis was conducted to assess the extent of distortion in the pooled prevalence of male involvement caused by publication bias.The results are presented in a forest plot, displaying a point estimate along with 95% confidence intervals.All analyses were performed using R software version 4.1.3.

Result Characteristics of the studies included in the meta-analysis and systematic review
Out of the 7,395 articles identified through different search strategies, 148 records were eliminated due to duplication.An additional 7,226 articles were excluded because their titles and abstracts were deemed inappropriate.Additionally, 9 were excluded due to noncompliance with the inclusion criteria.Finally, only 12 studies met the eligibility criteria and were considered in this study (Figure 1).This study incorporated a total of 7,109 participants from 12 studies, with sample sizes ranging from 198 to 2298 (13,(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)38) (Table 1).

Pooled prevalence of antenatal depression among HIV positive women in SSA
The overall pooled prevalence of antenatal depression among HIV positive women in SSA was 30.6% (95% CI, 19.8%-41.3%)(Figure 2).A subgroup analysis was conducted by country in SSA, revealing that the lowest prevalence was reported from African cohort, 6.5%, while the highest prevalence was reported from South Africa, 48.7% (Figure 3).

Assessment of publication bias
We used both subjective and objective measures to evaluate publication bias.First, funnel plot visual inspection was done.Then, we employed the Egger's test.Our findings revealed that the funnel plot displayed symmetrical distribution of studies in the line of effect (Figure 4).The Egger's test also noted a non-significant value for publication bias (P = 0.916).

Meta-regression and sensitivity analysis
The impact of study characteristics on the pooled estimate was assessed using meta-regression.However, none of the study characteristics, such as publication year and sample size, showed any association with the pooled estimates (P > 0.05) (Table 2).
To assess the impact of each study on the pooled estimates, a thorough sensitivity analysis was conducted by systematically excluding one study at a time.The results showed that almost all studies made comparable contributions to the overall prevalence of antenatal depression among HIV-positive women in SSA.When each study was omitted from the analysis, the pooled PRISMA flow chart showing the process of search and selection of studies included in the systematic review and meta-analysis.prevalence of antenatal depression ranged from 27.2% to 32.7% (Figure 5).

Factors associated with antenatal depression among HIV positive women in SSA
In this meta-analysis, we found significant factors associated with antenatal depression among HIV-positive women in SSA.These factors include being unmarried, employed, a previous history of depression, experiencing IPV, experiencing stigma, and ART non-adherence.
Two studies (13,28), involving a total of 806 participants, examined the association between unmarried HIV-positive pregnant women and developing antenatal depression.The random effect model analysis revealed a significant association between being unmarried and developing of antenatal depression.Thus, the odds of developing antenatal depression were three times higher among unmarried HIV-positive pregnant women compared to those married women (AOR: 3.09, 95% CI: 1.57 -6.07) (Figure 6).
Two studies (26,29) examined the correlation between a history of depression and the occurrence of antenatal depression.The overall estimate indicated that the odds of occurrence of antenatal depression were three times higher among HIV positive women with a previous history of depression compared to their counterparts (AOR: 2.97, 95% CI: 1.79 -4.91) (Figure 7).
Three studies (13,28,30) assessed the correlation between stigma experienced by HIV-positive pregnant women and the occurrence of antenatal depression.The overall analysis showed that those who had experienced stigma had 1.4 times higher odds of developing antenatal depression compared to those who had not experienced stigma (AOR: 1.36, 95% CI: 1.05 -1.76) (Figure 9).
Inconsistent findings were reported regarding the correlation between employment status and the occurrence of antenatal depression.Harrington et al. (26) found that employed women The forest plots show the pooled prevalence of antenatal depression among HIV positive women in Sub-Saharan Africa, 2024.

FIGURE 3
Forest plot showing the subgroup analysis of the pooled prevalence of antenatal depression among HIV positive women in Sub-Saharan Africa, 2024.had higher odds of experiencing antenatal depression, while Peltzer et al. (31) showed a negative association between employment and antenatal depression.The overall analysis indicated no significant association between employment status and antenatal depression (AOR: 0.94, 95%CI: 0.35 -2.53) (Figure 10).
Inconsistent findings have been reported regarding the correlation between non-adherence to ART and the occurrence of antenatal depression.Desalegn et al. (13) noted that HIV-positive pregnant women who were not adherent to ART had higher odds of developing antenatal depression, while Peltzer et al. (31) indicated that those who were not adherent to ART had lower odds of developing antenatal depression.The overall analysis showed no significant association between non-adherence to ART and the occurrence of antenatal depression (AOR: 1.06, 95%CI: 0.25 -4.39) (Figure 11).

Discussion
Despite the significant negative impact of antenatal depression on the health of both women and fetuses in Sub-Saharan Africa, it has received less attention than postnatal depression (46).As a result, there is limited data on the pooled prevalence of antenatal depression and its associated factors among HIV-positive women in the region.Therefore, this systematic review and meta-analysis aim to synthesize the available evidence on the prevalence of antenatal depression and its predictors among HIV-positive women in SSA.
The pooled prevalence of antenatal depression among HIVpositive women in SSA was found to be 30.6%(95% CI, 19.8%-41.3%),consistent with studies done in Ukraine (27%) (47), China (28.5%) (48), and America (36%) (49).However, this finding is higher than a study done in Bangladesh (18%) (50).This divergence might be due to the difference in the gaps in the study period, and source populations; in which most of the participants in the later study ( 50) included all pregnant women, regardless of HIV status.
On the other hand, this figure is lower than the 44% reported in a study conducted in the United States (51).The difference might be attributed to the timing of the study; for instance, a study in the United States was done during the COVID-19 pandemic and due to its higher transmission rates, HIV-positive pregnant women faced higher rate of depression (52).
According to this meta-analysis, unmarried HIV-positive pregnant women were found to have three times higher odds of developing antenatal depression compared to married women.This could be attributed to the increased vulnerability of single women to economic, social, and psychological hardships, which may contribute to higher rates of depression (53).Research has also shown that partner support plays a significant role in reducing depression during pregnancy (54).Furthermore, societal norms and cultural factors may contribute to the triggering of depression, as single motherhood is often not socially accepted in most African countries.
In line with study done by Biaggi A. et. al., 2016 (55), the odds of the occurrence of antenatal depression among HIV-positive women with a previous history of depression were three times higher compared to their counterparts.This might be due to the physical and hormonal changes occurring during pregnancy and the recurrence of depressive symptoms (56).However, contrary to this finding, a study conducted in Pakistan found that a personal history of previous psychiatric illness was not significantly associated with antenatal depression (57).
Consistent with study done in United States (58), the odds of developing antenatal depression among HIV-positive pregnant women were higher among women experiencing HIV-related stigma as compared to those who had not experienced stigma.This could be attributed to the fact that acquiring HIV, a chronic lifelong disease, often leads to significant levels of stigma.Also, some patients may choose to withdraw from society to avoid this stigma, which can further contribute to feelings of exclusion or loneliness and exacerbate depression.Forest plot displaying the association between being unmarried and antenatal depression HIV positive women in Sub-Saharan Africa, 2024.
Forest plot displaying the association between previous history of depression and antenatal depression among HIV positive women in Sub-Saharan Africa, 202.
Forest plot displaying the association between experiencing IPV and antenatal depression among HIV positive women in Sub-Saharan Africa, 2024.The study indicated that the odds of developing antenatal depression among HIV-positive women were two times higher among women who experienced IPV as compared to women who doesn't IPV.This could be explained by the fact that psychological, physical, and sexual violence perpetrated by an intimate partner can exacerbate depression (59, 60).
Additionally, the findings of this systematic review indicate that there is no substantial correlation between non-compliance with antiretroviral therapy (ART) and the incidence of antenatal depression.

Strength and limitation
This systematic review has several strengths.Firstly, we utilized a robust search algorithm to include studies from multiple databases.Secondly, our study provides the first-ever prevalence estimates of antenatal depression among HIV-positive women in Sub-Saharan Africa.Additionally, we identified the factors associated with the development of depression in HIV-positive women, which is crucial for preventive public health efforts.However, there are certain limitations to this review.Firstly, we only included articles published in English.Secondly, the cross-sectional design of the included studies may limit our ability to establish a causal association between antenatal depression in HIVpositive women and the associated factors.Lastly, some factors were only reported in a single study, preventing the calculation of a pooled effect size.

Conclusion
The high prevalence of antenatal depression among HIVpositive women in SSA and the significant factors associated with it underscore the need for healthcare providers to prioritize the identification and management of antenatal depression in this population.Interventions addressing the underlying factors contributing to antenatal depression should be developed and implemented.Healthcare providers should also be trained to recognize the signs and symptoms of antenatal depression and provide appropriate support and referrals for mental health services when needed.Addressing antenatal depression among HIVpositive women in Sub-Saharan Africa can improve maternal and child health outcomes and reduce the burden of mental illness in this population.

FIGURE 11
Forest plot displaying the association between ART non-adherence and antenatal depression among HIV positive women in Sub-Saharan Africa, 2024.Forest plot displaying the association between presence of stigma and antenatal depression among HIV positive women in Sub-Saharan Africa, 2024.

FIGURE 10
Forest plot displaying the association between being employed and antenatal depression among HIV positive women in Sub-Saharan Africa, 2024.

FIGURE 4 Funnel
FIGURE 4Funnel plot showing publication bias among studies used to compute the pooled prevalence of antenatal depression among HIV positive women in SSA, 2024.

FIGURE 5
FIGURE 5Sensitivity analysis for the pooled prevalence of antenatal depression among HIV positive women in Sub-Saharan Africa, 2024.

TABLE 1
Characteristics of studies included in the meta-analysis.
Key; N = Total sample size.

TABLE 2
Meta regression analysis of factors affecting between study heterogeneity.